Emotional Awareness and Expression Therapy vs Cognitive Behavioral Therapy for Chronic Pain in Older Veterans

Key Points Question Is group-based emotional awareness and expression therapy (EAET)—a psychological intervention targeting trauma and emotional processing—superior to cognitive-behavioral therapy (CBT) for treatment of chronic pain in a racially and ethnically diverse cohort of older veterans? Findings In this randomized clinical trial with 126 participants, those randomized to EAET had significantly greater improvements in the primary outcome of reduction in pain severity from baseline to the primary end point of posttreatment (week 10). Moreover, 63% of EAET participants had clinically significant (at least 30%) posttreatment pain reduction vs only 17% in CBT. Meaning These findings support the superiority of EAET compared with CBT in reducing chronic pain among older veterans.

a The primary outcome was the average of the four pain severity items of the BPI, 46 which measure current pain and worst, least, and average pain over the last 7 days, each on a 0-10 scale.
b The PROMIS Anxiety Short Form 7a 48 includes 7 items assessing anxiety symptoms over the last 7 days, each rated 1-5 for total scores ranging from 7 to 35; higher scores indicate greater anxiety.c The PROMIS Depression Short Form 8a 48 includes 8 items assessing depressive symptoms over the last 7 days, each rated 1-5 for total scores ranging from 8-40; higher scores indicate greater depression.d The PROMIS Fatigue Short Form 7a 49 includes 7 items assessing symptoms of fatigue over the last 7 days, each rated 1-5 for total scores ranging from 7 to 35; higher scores indicate greater fatigue.e The NIH Toolbox General Life Satisfaction Fixed Form B 50 includes 5 items assessing the degree to which participants agree or disagree with statements about life satisfaction; each item is 1-5 for total scores between 5 and 25, and higher scores indicate greater life satisfaction.f The PROMIS Pain Interference Short Form 8a 51 includes 8 items assessing pain's interference with mood and activities over the last 7 days, each rated 1-5 for total scores ranging from 8-40; higher scores indicate greater pain interference.
g The PROMIS Sleep Disturbance Short Form 8a 52 includes 8 items assessing sleep disturbance over the last 7 days, each rated 1-5 for total scores ranging from 8-40; higher scores indicate greater sleep disturbance.h The PCL-5 55 includes 20 items on post-traumatic stress disorder symptoms related to the most stressful experience in life, each rated 0-4 for total scores between 0 and 80.

eTable 2. Differences between those with and without missing posttreatment or follow-up
Abbreviations: BPI, Brief Pain Inventory; CBT, cognitive-behavioral therapy; EAET, emotional awareness and expression therapy; PCL-5, PTSD Checklist for DSM-5; PROMIS, Patient Reported Outcomes Institute Measurement System.

Descriptive statistics for primary and secondary outcomes
Sample sizes for the PCL-5 are Complete Case, n=81; Missing Posttreatment or 6-month follow-up, n=18.eTable 3.

Toolbox General Life Satisfaction Fixed Form B
Patient Global Impression of Change 53 is a single item rated 1-7 assessing change in activity limitations, symptoms, emotions, and quality of life since beginning treatment; higher scores indicate greater improvement.b PCL-5, PTSD Checklist for DSM-5 c Satisfaction with Therapy subscale of the Satisfaction with Therapy and Therapist Scale-Revised (STTS-R) 54 includes 6 items rated 1-5 for possible scores ranging from 6 to 30; higher scores indicate better satisfaction.d Satisfaction with Therapist subscale of the STTS-R 54 includes 6 items rated 1-5 for possible scores ranging from 6 to 30; higher scores indicate better satisfaction.e Single item of the STTS-R 54 rated 1-5; higher scores indicate better satisfaction.© 2024 Yarns BC et al.JAMA Network Open.: 95% CI, 95% Confidence Interval; CBT, cognitive-behavioral therapy; EAET, emotional awareness and expression therapy; a PROMIS, Patient Reported Outcomes Institute Measurement System; b PCL-5, PTSD Checklist for DSM-5 (Sample sizes for the PCL-5 are EAET, n=52; CBT, n=47).*p<.05; **p<.01;***p<.001.
a Abbreviations